Extending the Reach of Interventions to Treat Mental Disorders

Abstract

The majority of people with mental disorders in low-, middle-, and high-income countries do not receive any intervention for their symptoms, despite enormous advances in developing evidence-based psychosocial treatments and medications. The perspective and viewpoint article discusses and illustrates digital and technology-based interventions and activities in everyday life that have been shown to reduce symptoms of mental disorders. The article begins with background on the treatment gap and a discussion of why treatments do not reach people in need. Digital and technology-based interventions and everyday activities are presented to complement current treatments with the goal of scaling interventions to serve more people in need and to circumvent many of the usual barriers that preclude people from seeking or receiving traditional mental health services. Interventions in each of the categories are illustrated. The challenge is to integrate such interventions in mental health practices, to better promote these at the population level, and to monitor their impact.

1. Introduction

Worldwide, the need for treatment of mental disorders is enormous. The prevalence rates of mental health problems are high and on the rise. There are many effective treatments, but these do not reach the majority of people in need of services. Barriers to seeking and obtaining mental health services, such as lack of insurance and stigma, among many others, are well known. This is a perspective and viewpoint article, rather than a literature review. The purpose of this article is to discuss interventions that circumvent the traditional barriers of mental health services and that can be scaled to reach large numbers of individuals in need.

The article begins with the context to convey the scope of mental health problems and why so few people obtain treatment. To expand the range of intervention options, two nontraditional types of treatment are discussed, namely, digital and technology-based interventions and activities in everyday life. These interventions do not require seeking mental health services, going to therapy, taking medications, or even viewing oneself as having a mental health problem. The interventions are not proposed to replace current treatment approaches but rather to expand the range of options and to reduce the tremendous gap between those who need and those who receive interventions. The article illustrates interventions and highlights the evidence in relation to the effects on mental health problems.

2. Background: The Mental Health Treatment Gap

The treatment gap refers to the discrepancy in the number of people with mental health problems versus the number who actually receive any treatment [1,2,3]. The gap is well documented in research spanning the globe and across many mental disorders (e.g., depression, anxiety, and schizophrenia), age groups, and cultures [4,5,6]. Each component is considered briefly as a background for the need to expand the range and type of services to reach people with mental health problems.

3. Scope of Mental Health Problems

There are a variety of mental health problems that impair the functioning of children, adolescents, and adults. The most familiar are formally recognized psychiatric disorders (e.g., depression, anxiety, eating disorders, substance use and addictive behaviors) [7,8]. Psychiatric disorders are highly prevalent worldwide. As an illustration, a recent report evaluated prevalence rates sampling over 156 thousand adults, from 29 countries, including 12 low-income and middle-income countries and 17 high-income countries. Overall, approximately 50 percent of individuals met criteria for a psychiatric disorder by the age of 75 [9]. This study included 13 of the most common disorders (e.g., variations in depression and anxiety, attention-deficit/hyperactivity, alcohol and drug abuse disorders, among others).

The prevalence rate of approximately one-half of the population over the life course is likely to be an underestimate. National and international surveys routinely exclude some disorders (e.g., schizophrenia, autistic spectrum disorder) because individuals with these disorders are not readily assessed via surveys and omit populations with high rates of mental disorder (e.g., individuals in prisons or psychiatric hospitals or who are without housing). If these disorders and samples were included, the prevalence rates of the entire population would be much higher. Even within the restricted focus, prevalence rates have been increasing for the past decade for children, adolescents, adults, and older adults [10,11].

Subclinical disorders are defined as not quite meeting the psychiatric diagnostic criteria. These are important because they can cause impairment and increase the risk of meeting the full psychiatric diagnostic criteria in the future. These, too, are relatively prevalent. For example, a large-scale survey in the United States evaluated over 36,000 adults sampled from all 50 states [12]. The survey examined lifetime rates of subclinical disorders and covered 14 of the most common disorders. Overall, there was a 57 percent lifetime prevalence of having at least one of the subclinical disorders.

Other impairing conditions are significant and on the rise. Loneliness and social isolation are two such conditions: loneliness is a subjective experience and perception; social isolation is objective in the sense that it refers to a lack of contact with other people. Loneliness and social isolation can go together, but they are separate and can be readily distinguished. For example, people living alone with few or no social contacts (socially isolated) are not necessarily lonely. Also, people in contact with others (e.g., spouse, partner, individuals at work or other activities) are obviously not socially isolated but can still be lonely. Loneliness and social isolation can be impairing conditions, predict the onset of a variety of physical and mental disorders (e.g., Alzheimer’s disease, sleep and eating disorders, suicidality), and are associated with a reduced life expectancy [13,14]. For example, many people experience loneliness. One review of studies found that 80 percent of the population younger than 18 years and 40 percent of the population above 65 years reported loneliness at some point in their life [13]. A study of approximately 1200 individuals (ages 15–97) in the United Kingdom found that 6 percent of the participants were lonely all or most of the time [14]. Loneliness and social isolation are now recognized worldwide as a public health priority in light of their deleterious consequences on both physical and mental health [15].

The consequences of untreated mental health problems for individuals, their families, and society at large are enormous. For the individual, the presence of a psychiatric diagnosis decreases life expectancy. People with severe mental health disorders (schizophrenia, depression, and bipolar disorder) have a 10–25 year reduction in life expectancy [16,17]. Yet earlier than expected mortality is applicable to psychiatric diagnoses other than these more severe disorders (e.g., anxiety disorders) [18]. Early death is primarily the result of infectious disease (e.g., HIV, hepatitis, and tuberculosis), chronic health conditions (cardiovascular disease), other psychological conditions and their consequences (e.g., suicide), and social conditions (e.g., poverty, underrepresented group status). Subclinical disorders, loneliness and social isolation are also associated with physical disorders and reduced life expectancy [18,19]. The financial burden of mental health problems worldwide is large, as reflected in emergency room visits, social services, disability payments, and losses to business and industry, among other costs [20,21].

4. Treatment Delivery to Those in Need

Most people with a psychiatric diagnosis do not receive treatment, as reflected in a World Health Organization survey [22]. The percentage of people in need who received treatment increases as a function of country income (13.7 percent from low-to-middle-income countries, 22.0 percent from middle-income countries, and 36.8 percent from high-income countries). Even in the high-income countries, the majority of individuals with a mental disorder do not receive treatment.

If one considers specific disorders, the gap in services is further corroborated. For example, a large-scale report evaluated major depression in 21 countries: 10 countries classified as low- or middle-income: Brazil, Bulgaria, Colombia, Iraq, Lebanon, Mexico, Nigeria, the Peoples Republic of China, Peru and Romania; and 11 classified as high-income (Argentina, Belgium, France, Germany, Israel, Italy, Japan, the Netherlands, Portugal, Spain and the USA) [23]. The proportion of individuals receiving treatment for depression was relatively small. In high-income countries, one in five (20 percent) individuals with depression received treatment. In low- and middle-income countries, 1 in 27 (3.7 percent) received treatment. The low rates of receiving treatment are similar for other disorders (e.g., schizophrenia, substance use disorder, and others) [24,25,26].

We do not merely want individuals to receive treatment but also to receive the best available treatment. In the past 50 years, there has been great progress in identifying effective treatments, including various forms of evidence-based psychotherapy and medication [27,28,29]. We begin with the point that most people in need of mental health services receive no treatment. Among those who do receive treatment, only a small proportion receive a treatment that is evidence-based. For example, a large-scale survey of adults (>56,000, 18 years or older) from 21 countries, sampling low-, middle-, and high-income countries, found that among individuals who received treatment across a wide range of mental disorders, only 6.9 percent received an intervention (psychotherapy and or medication) that followed evidence-based guidelines [30]. Studies that have focused on specific disorders (e.g., depression and posttraumatic stress disorder) also show that only a small proportion of those who receive treatment receive one that is evidence-based [31,32].

5. General Comments

I have sampled only a few studies from a much larger set looking at the prevalence of mental health problems worldwide and the proportion of individuals who receive treatment. Also, the specific percentages among studies can vary as a function of the number of disorders or treatments sampled and who is included in the survey. Even so, a few points remain clear across studies and are worth underscoring:

• Mental health problems, including psychiatric disorders, subclinical disorders, and other problems (loneliness, social isolation), are pervasive. The psychiatric disorders alone affect 50% of the population over the course of their lives.
• The problems are on the rise for children, adolescents, adults, and older individuals. This does not appear to be due to better assessment or diagnoses, but genuine increases in impairments.
• The majority of individuals with mental health problems do not receive treatment, and that applies to individuals in countries spanning all economic levels.
• When people do receive treatment, it is rarely an intervention that is evidence-based. Clearly, a priority is not only to ensure that more people in need receive services, but when they do, that they receive those that are evidence-based.

The current means of delivering treatment do not meet the huge need for services. The impetus for this article is to address additional means of providing interventions that can be scaled to reach more people in need. Yet, merely adding treatments is not likely to be helpful without considering why most people do not receive treatment.

6. Why People in Need Do Not Receive Services

The reasons why most people do not receive treatment have been well studied [26,33,34]. Two broad categories of barriers to treatment can be distinguished and include structural or system factors (e.g., financial costs, whether a service is available, and policy issues), and attitudinal factors (e.g., stigma, mental health literacy, views that treatment will not be of much help).

Table 1. Barriers to mental health care.

Barrier Type	Brief Description
System Factors Cost of mental health services	Treatment is not affordable because services are not covered by the client’s insurance, are not completely covered, or the out-of-pocket costs are too high. Understanding what is and is not covered or negotiating the process of this (reimbursement forms, appealing after a claim has been refused) can be daunting.
Policy and legal constraints	Government (e.g., federal, state, province, and city) as well as third-party payers’ policies may restrict what conditions can be treated and reimbursed or for how long treatment can be provided (e.g., number of sessions, days) and still be reimbursed. These limit what services may be available.
Too few providers to deliver services	Mental health professionals are not available in sufficient numbers to meet the need. This is a global problem in low-, middle-, and high-income countries. Too few service providers meet the ethnic demographic profiles of the public and may not focus on clinical populations or problems for which the need is great.
Attitudinal Factors Stigma	Concerns among potential clients or consumers of treatment include being labeled (diagnosed) with a mental disorder or being associated with treatment for a mental disorder. Stigma can lead to genuine discriminatory practices and domains of rejection (e.g., employment, promotion). Also, individuals may view their own problems with stigma (self-stigma), which can interfere with seeking treatment.
Mental health literacy	Information individuals have and what they know about mental disorders, whether one has symptoms or a disorder that warrants treatment, what the options are for treatment, and how to pursue those options and obtain treatment.
Ethnic and cultural influences	Ethnic and underrepresented groups within a culture have less access to services for health care in general, including mental health care. Views about whether psychological problems warrant treatment, entry into any health care service, and seeking treatment can vary widely. Some problems (e.g., anxiety, depression) may not be seen as a reason to seek “treatment” or to be involved with a health care system.

Note. References to reviews in the text provide a more comprehensive evaluation of barriers and the research that addresses their impact.

lists the categories of barriers with examples. It is important to underscore that these barriers often come in packages. That is, an individual is likely to experience many barriers, such as lack of insurance, stigma and self-stigma, and others in various combinations [35,36,37].

Although the barriers are summarized in the table, it is useful to consider a few in more detail. As an example, one of the most critical factors in whether a person has insurance to cover their care; this applies to low-, middle-, and high-income countries [21,38]. This barrier alone can preclude millions of individuals from seeking treatment for their mental (but also physical) health problems. Also, there are ambiguities about insurance in the sense that people are not sure of whether treatment for mental disorders will be reimbursed when they have insurance. Occasionally, companies refuse claims, and individuals who thought their treatment would be covered are wrong. Thus, the lack of insurance or worries about coverage often preclude seeking treatment.

As another example, stigma and self-stigma are among the most well-known barriers. Stigma is associated with a variety of consequences in relation to discrimination, stereotypes of others, reduced self-esteem, and increased social isolation [39]. Understandably, individuals are reluctant to seek “treatment” for a “mental disorder” for fear of suffering from the ensuing consequences [40,41]. And this is not just the consequences of others. Self-stigma entails how individuals may negatively judge or view themselves if they see their problem as a mental disorder. The greater the degree of perceived stigma, the less likely one is to seek treatment [42,43]. In general, any one barrier can prevent someone from seeking treatment. Yet usually it is not one barrier (e.g., lack of insurance or no treatment service nearby) that limits receipt of treatment but rather multiple barriers that come together, as I mentioned. This makes delivering treatment at all, yet on scale, a major challenge.

7. Interventions: Beyond Traditional Mental Health Services

Traditional mental health services for psychiatric disorders include a variety of psychotherapies, many of which are now evidence-based. Yet, as noted previously, such services, whether evidence-based or not, rarely reach individuals in need. Apart from the barriers mentioned, the model of service deliver precludes large-scale application. The vast majority of psychosocial interventions—various forms of cognitive–behavioral, relationship-based, and other therapies—are usually delivered as follows:

• Treatment sessions are provided in person and one-to-one with a client (individual, couple, or family);
• Treatment is administered by a highly trained (e.g., master’s or doctoral level) mental health professional (e.g., psychologist, psychiatrist, social worker, family therapist);
• Sessions are held at a clinic, private office, or health-care facility.

So few people can be treated with this model. Among the reasons is that there are not enough mental health professionals engaged in clinical practice to meet the need; those that are available are located primarily in urban areas. Most are trained in delivering services to adults, with few trained to provide services to children, adolescents or older individuals, where the need is great; and relatively few match the ethnic and cultural characteristics of the range of individuals in need of services [44,45,46].

There have been many innovations in delivering services including efforts to engage people in treatment [47], integrating mental and physical health services in the same treatment setting [48,49], developing urgent-care centers to bring mental health services closer to people in need [50], conducting treatment in nontraditional settings (e.g., beauty parlors, barber shops) [51,52], using lay therapists [53], providing only one treatment session [54], and making helplines (by phone or computer) available to provide crises management [55,56]. All efforts to extend treatment are to be encouraged. Unfortunately, to date, there is no evidence that these efforts have reduced the treatment gap. Indeed, many have already been in place for years. In addition, many of these efforts still retain the burdens of seeking “mental health treatment,” as highlighted in Table 1. Complementary interventions are needed to provide options without these same burdens. Two broad categories are highlighted that could expand the range of individuals who receive effective treatment.

8. Digital and Technology-Based Interventions

A large number of interventions are available online or via mobile devices, utilize social media, or draw on other technologies [57,58,59].

Table 2. Select technologies, media, and digital means of delivering mental health interventions.

Medium	Defined
Telepsychiatry/ Telemedicine	Treatment provided at a distance originally dominated by telephone, but more recently provided by video.
Applications (apps) and the Internet (E-mental health)	E (electronic)-mental health includes a range of services and platforms such as applications (“apps”), the internet, games for smart devices, websites, wearable sensors, and social media.
Chatbots	A software or internet application that is designed to mimic human conversation through text or voice interactions. They simulate conversations with humans.
Short Message Service (SMS)	A way of sending text messages, which permits the exchange of these messages between mobile devices and other smart devices.
Virtual Reality & Augmented Reality	VR provides a computer-generated three-dimensional (3D) simulation experience that delivers a realistic rendition of images, sounds, and occasionally olfactory and tactile stimuli. One interacts in a realistic way using specialized equipment, usually a headset display. VR can create realistic settings and situations to provide individuals with the experience of being present in the specific setting or situation. AR is a computer-generated simulation. Instead of being completely artificial and simulated as in VR, AR permits one to add images, sounds, graphics, and characters (avatars to represent people) to real environments that appear to the participant.
Socially Assistive Robots	Robots that can interact with humans. They often draw on artificial intelligence, large or natural language models (to develop natural or conversational language), and machine learning to guide interactions. They help users in social rather than physical interactions and can provide guidance, support, motivation, and feedback toward a specific goal (e.g., education, learning, and training).

Note. This is only a sample of technology-based interventions that have been applied to mental health problems. A review of their use and evidence is available elsewhere [60].

lists many of the media used to deliver treatments for mental disorders. Within each medium, there are many specific options. Three examples to convey the effects and diversity of the interventions.

Online Treatments. Several programs are available to treat depression. Among the most well-established programs is Beating the Blues (www.beatingtheblues.co.uk). The computerized treatment is interactive, multi-media, and draws on cognitive behavioral treatments. Treatment can be completed without the need for a therapist. Treatment begins with a 15 min introductory video; then eight weekly sessions are provided by computer. The sessions assign activities to do at home. Separate modules are presented (e.g., related to automatic thoughts, core beliefs, and attributional style), and treatment can be individualized by additional modules that may also apply, such as graduated exposure if the patient has anxiety. Evidence supports the effectiveness of the program as a treatment for depression and anxiety [61,62]. There are now multiple online programs for the treatment as well as prevention of depression and anxiety [63,64,65].

Another online program, MindSpot, provides treatment primarily for anxiety, depression, obsessive–compulsive disorder, post-traumatic stress disorder, and pain management [66,67]. Approximately 30,000 patients can be treated annually, and the treatment is free to residents of Australia 18 years or older. Mindspot is a digital course based on evidence-based psychological treatment (e.g., cognitive therapy, behavioral activation, graded exposure, problem solving, and relapse prevention). The course is delivered online over an 8-week period with regular support initiated from the therapist once a week, either via telephone, secure email, or both.

Extensive data collection over multiple years shows improvements in symptoms across multiple symptom domains. Follow-up three months after treatment indicated that improvements are maintained. Clients report satisfaction with the interventions. Among the reasons are convenience, lack of cost, and privacy and anonymity as they pursue treatment. In an evaluation over a seven-year period, between 28 and 38 percent of clients reported that they had not previously seen a mental health profession for their mental health problems. Overall, this provides a user-friendly service. There are other variations in free online, telephone, and digital-based treatments with outcome data that further support the impact of treatment delivered in this way to individuals with mental health problems [68].

Serious Games. There are many variations in applications (apps) and games that are very familiar to many users. A special group of these is referred to as serious games, which are programs that capture the motivational and engagement benefits common among games devoted to entertainment but with other goals (e.g., training, education, skill acquisition). These games are available in different formats, including mobile apps, internet, video, and virtual reality, but video is the most common. Many of these games are efforts to convert evidence-based psychotherapies for mental health problems into a digital and game-like format. That is, they “gamify” techniques such as cognitive behavior therapy, biofeedback, and cognitive training. There are scores of games for children, adolescents, and adults.

For example, one intervention is SPARX (smart, positive, active, realistic, X-factor thoughts), a serious game designed to reduce depressive symptoms among adolescents via cognitive behavior therapy. The player chooses an avatar that undergoes various challenges to achieve balance in a fantasy world dominated by GNATs (gloomy negative automatic thoughts). At the beginning and end of each of seven modules, the user interacts with a guide who puts the game into context, provides education, gauges mood, and sets and monitors real-life challenges that are equivalent to the homework assignments often provided during in-person therapy.

Another example is Mindlight, a serious game for children that focuses on managing anxiety and stress. The game begins with a character left at the doorstep of a scary mansion, faced with the task of saving his grandmother from the evil forces that have possessed her and the house. Inside, he finds a glowing headset that teaches him (and the player) to overcome his fears by changing his state of mind. As the player traverses the dark mansion, they indicate how they are feeling. Several evidence-based strategies for decreasing anxiety are embedded in the game.

My examples mention serious games for youth. This is important because approximately one-half of mental disorders emerge in childhood and adolescence, and increasing viable treatment options for these periods is important [69]. However, serious games are readily available for adults. The research is at a relatively early stage, with evidence suggesting that serious games are effective interventions, especially for anxiety and depression, where they have been most well studied [70,71].

Socially Assistive Robots (SARs). These are robots that can interact with humans as well as with other robots. They draw on artificial intelligence, natural language models (to develop conversational language), and machine learning to guide users in social interactions and can provide guidance, support, motivation, and feedback toward a specific goal (e.g., education, learning, and training). They can be capable of lifelike expressions, gestures, bodily movements, and verbal communication as they interact with the user.

SARs can take many different physical forms, including an animal (dogs, cats, seals, and small dinosaurs), human, or novel creative objects of various shapes and sizes [72,73]. In terms of mental health care, SARs have primarily been used with older individuals, usually those with cognitive impairment or neurodevelopmental disorders (e.g., dementia, Alzheimer’s) and with children with autism spectrum disorder [74,75,76,77].

A prominent example is named Paro, which is designed to resemble a baby harp seal, complete with synthetic fur [78]. It can perceive people and the environment, can tell when its fur is being stroked, and can recognize the direction of the user’s voice, its name, and greetings. Paro is used with children as well as adults and for individuals with mental health problems and physical disorders (e.g., to reduce anxiety and pain among cancer patients). The main applications have been to overcome loneliness and social isolation, which are especially prevalent among older individuals in light of special circumstances that can arise in this period of life, such as loss of a partner and friends, physical disability that restricts participation in activities, and living in centers away from family.

Paro has been used in many countries and evaluated in controlled trials with older individuals often having dementia and in long-term care settings. The benefits include reductions in loneliness and social isolation, depression, anxiety, stress, pain, and physical and verbal agitation, and increases in positive mood, happiness, and quality of life [79,80,81]. Paro has dominated SAR work with older individuals, but other robots have shown positive effects as well [82].

9. General Comments

In short, technology has many options that provide effective interventions for mental health problems, only a few of which have been highlighted. Thousands of apps and other options continue to emerge, and this is a potential strength as well as a genuine weakness. The strength is the ability to reach large numbers of individuals of all ages without the burdens that restrict seeking traditional mental health services. The weakness is that there are thousands of digital-based interventions, and they continue to emerge. They are rarely studied empirically, and there is no easy way for the public or health-care professionals to identify which interventions are effective based on the evidence. This means that advertising and reviews (by users) often serve as the basis for selecting a given intervention. There is a need for a clearing house and identify which ones are effective based on evidence.

Even so, interventions delivered digitally or via technology hold great promise because they are not subject to the same barriers as traditional mental health treatments. So much of the world is connected to digital interventions, so they are feasible on a large scale. For example, 91 percent of US adults have smartphones; 60 percent of the world population [83]. Thus, the potential reach of such interventions is enormous.

10. Everyday Life Activities

Activities in everyday life are often touted as beneficial in relation to mental health (e.g., quality of life, subjective well-being). By everyday life activities, I refer to familiar experiences such as going for walks, spending time with friends, engaging in a hobby, gardening, watching television or playing video games, and many others. Many of these activities are “free,” and most importantly, are largely free of the many barriers (e.g., lack of treatment facilities, no insurance, stigma, or self-stigma) associated with seeking treatment for mental health problems. Of course, the critical question for the present purpose is whether there is evidence that common everyday activities can reduce mental health problems.

Table 3. Select interventions from everyday life with beneficial effects on mental health problems.

Activity	Defined
Physical Activity/Exercise	Physical activity refers to engaging in movement or action that is sustained for a specific period of time and includes both structured activities (e.g., games, sports, and exercise classes) and unstructured activities (e.g., going for walks, doing household chores, and gardening).
Contact with Nature	Interaction with some facet of the natural environment, including wilderness, mountains, forests, oceans, lakes, and other open areas. Gardens and parks with foliage, nonhuman animals, and more generally the sights, sounds, fragrances, and ambience of the outdoors are central, whether in a city or a wilderness area.
Diet and Nutrition	Foods, beverages, nutrients (e.g., vitamins, minerals), and special multicomponent nutritional supplements that can be consumed and are intended to improve health.
Yoga	A spiritual discipline and set of practices designed to bring harmony between the mind and body. Encompasses many components that include a variety of movements, postures, breath control, relaxation, mindfulness, and meditation.
Tai Chi/Qigong	Tai chi has an overall goal to connect mind, body, and spirit and bring serenity to the individual. The practice includes sequences of very slow, controlled, and flowing movements to address strength, endurance, balance, and mobility of the body. Qigong involves breathing patterns (slow, long, and combining with speech), movements of the whole body that are slow, smooth and directed toward achieving a relaxed state and focusing one’s attention.
Mindfulness and Meditation	Mindfulness is directed toward attaining liberation from the impermanence of nature and suffering. Key components are focusing on the present moment, observing or being aware of one’s thoughts, emotions, sensations and momentary experiences, and adopting a nonjudgmental attitude towards one’s experience of the internal or external world. Meditation emphasizes the importance of attention focused on an object or single thought until the mind achieves calmness and quieting of intrusive other thoughts.
Social Contacts	Interaction with others that can take many forms, depending on the contacts (e.g., family, friends, teachers, colleagues, and peers), diverse settings (e.g., work, at school, and community) and whether contacts are in person and face-to-face or through a variety of media.
Interactions with Pets and Other Nonhuman Animals	Contact with animals in diverse contexts—most commonly with one’s pet, but also includes emotional support animals, and animal visitation programs.
Spirituality and Religion	Spirituality refers to the search for meaning in life and a belief in a broad or transcendental realm beyond the mundane and everyday experience. Religion is an institutionalized system of practices, beliefs, and attitudes.
Volunteering	Participating in an activity in which one gives time and effort to provide some service or assistance, invariably without receiving external compensation. The service is intended to directly benefit someone else or an agency that serves others.
Hobbies and Leisure Activities	An activity or interest that is pursued for enjoyment and relaxation, often done in one’s spare time and for which there usually is no interest in making a profit.

Note. The table identifies several common activities and is not intended to be exhaustive. Evidence for the effectiveness of these activities in relation to mental health problems is reviewed in detailed elsewhere [60].

lists many of the activities. Two examples with a strong evidence base are provided to convey the effects and diversity of the interventions.

Physical Activity And Exercise. Physical activity refers to engaging in movement or action that is sustained for a specific period of time. Both structured activities (e.g., games, sports, and exercise classes) and unstructured activities (e.g., going for walks, doing household chores, and gardening) are included among the physical activities that have many beneficial effects. Duration, type, and frequency of activity are important. For adults, recommended activities include 150 min of moderate-intensity physical activity and two days of muscle-strengthening activity each week [84,85]. Yet the benefits for both physical and mental health emerge from less than the recommended dose. For example, mild-to-moderate intensity activity (10–30 min) reduces depression, and the effects extend among diverse ethnic groups [86,87].

From observational studies, we know that individuals who engage in regular physical activity have lower rates of depression, anxiety, loneliness, social isolation, stress, and negative affect and higher rates of positive affect and overall well-being [88,89,90]. Yet exercise is often part of a lifestyle that includes other habits that are related to current mental health and reduced risk for mental health problems (e.g., lower rates of cigarette smoking, less consumption of alcohol, and better diet and nutrition). However, controlling for such influences reveals that physical activity improves many mental health outcomes [91,92].

Multiple reviews of research have concluded that physical activity can improve symptoms of anxiety disorders, obsessive–compulsive disorder, posttraumatic stress disorder, eating disorders, attention-deficit/hyperactivity disorder, autism spectrum disorder, substance use disorders, and schizophrenia/psychosis [89,93,94,95,96,97]. In one meta-analysis, for example, over 190 thousands adults were included, and the results indicated that physical activity could reduce the risk of onset of depression and symptoms of depression among those with the disorder [98]. Findings indicate that exercise below the recommended levels leads to the benefits, but greater improvements have been reported with exercise of higher intensity and of a longer duration [99].

Physical activity is not a panacea for all mental health woes. Yet there are many noteworthy features of physical activity, beginning with a strong evidence base. Also, physical activity (e.g., walking) is readily available in everyday life. There are many physical activity and exercise options for individuals of all ages, and one can change or vary the activity and still reap the benefits. Such activities are free from the usual barriers associated with seeking “treatment” for “mental illness.” Finally, physical activity is acceptable to potential consumers. We see people exercising all the time in everyday life, on television and other social media, and as part of all sorts of community-related events (e.g., 5K runs for charity or some other cause). Physical activity has its own obstacles and is not available for everyone. Even so, it is a viable intervention to extend on a large scale to treat or prevent mental health problems.

Yoga. Yoga is a spiritual discipline and set of practices designed to bring harmony between the mind and body. The discipline has a history beginning in India, extending thousands of years [100]. Over the years, the practice has become global [101]. Yoga encompasses many components that include a variety of movements, postures, breath control, relaxation, mindfulness, and meditation. The many styles of yoga vary primarily in their emphasis on these different components [102,103]. The different body postures, controlled breathing/breathing exercises, and meditation are intended to harmonize a person’s mental and physical states. There is no definitive count of yoga techniques [104,105]. A review of research sampling 306 controlled trials documented 53 versions of yoga [106]. Different types are used and applied to a vast array of problems, with no clear evidence that one version is more or the most effective for a given mental or physical health problem. Indeed, most of the research does not specify the type of yoga that was included [107].

There are now hundreds of (>300) reviews of the effects of yoga on mental and physical health [107,108,109]. The strongest evidence appears for the reduction in depressive symptoms [110,111,112]. However, research has also supported the benefits of yoga for symptoms of anxiety, posttraumatic stress disorder, obsessive–compulsive disorder, eating disorders, substance dependency, and schizophrenia [106,113].

Considerable work has also shown that yoga can reduce loneliness and social isolation. Most of the work has been conducted with older individuals (>65 years), but similar findings have been obtained with children and adolescents [114,115,116]. A more frequent focus has been the impact of yoga on stress. Many studies now show that yoga reduces self-reported stress as well as several biological indices of stress (e.g., cortisol, systolic blood pressure, heart rate, and heart rate variability) [117,118]. Overall, the evidence in favor of yoga for improvement in mental health problems is extensive.

Yoga is one of many mind–body interventions and Eastern interventions that have been examined in relation to mental health problems. For example, mindfulness has been shown to reduce eating disorders, addiction, symptoms of psychoses, attention-deficit/hyperactivity disorder, loneliness, social isolation, and stress [119,120,121]. Tai chi and qigong are less well investigated than are yoga and mindfulness. Even so, for both tai chi and qigong, reviews of research indicate the benefits in relation to reductions in depression, anxiety, loneliness, social isolation, and stress and improvements in overall well-being [122,123,124,125].

These interventions expand the range of what can be done for mental health problems. They are usually initiated by individuals for physical health and well-being, and hence, do not carry the barriers associated with seeking treatment for mental health problems. Yoga already is heavily practiced throughout the world in low-, middle-, and high-income countries, and its extension and promotion might well be feasible to have impacts on the treatment and prevention of mental health problems.

General Comments. There are many other activities in everyday life, including contact with nature, spirituality, volunteering, engaging in hobbies and leisure activities, and contact with nonhuman animals that have been shown to reduce mental health problems in varying degrees. Overall, they reflect a critical point for the present article, namely, there are a variety of activities that reduce symptoms of mental disorders, loneliness, and social isolation.

I have focused on the impact of interventions on mental health problems, and omitted many other benefits, including those on physical health, overall well-being, and quality of life. These are important, of course, but the bar was set elsewhere for the present article. The focus has been on identifying what can be done to complement traditional mental health treatments and what can achieve reductions in significant mental health problems.

Each intervention will have its own obstacles and barriers. For example, walking on a regular basis is likely to have significant benefits for mental health problems, in keeping with the extensive research findings on physical activity. However, walking is not a viable option for many people, in light of physical disability or perhaps living in an area or neighborhood where there is danger. Yet the goal of the article is to identify a range of interventions that circumvent the enormous barriers associated with seeking treatment for mental health problems (e.g., insurance, stigma and self-stigma). Activities in everyday life provide a viable and rich set of options that allow reaching people in many different ways.

11. Limitations and Qualifications

Novel interventions, with evidence that has been highlighted, address significant mental health problems (e.g., depression, anxiety, and loneliness). It is important to be clear about what is being presented. To begin, I am not proposing that digital and technology-based interventions or everyday activities replace traditional mental health interventions. The goal is to expand the many ways in which individuals can be helped, with attention to those interventions that have a basis in evidence. The findings have been well established that current treatments are not utilized or available to the vast majority of individuals in need of mental health services. The novel interventions noted here have a basis in evidence, can be scaled, and increase the options for people in need who might be reticent to seek traditional mental health services. The goal was to expand the range of viable options with the goal of reducing the treatment gap.

Another point is critical to underscore. There are broad issues that contribute both to the prevalence of mental health problems and the delivery of services to those in need. These are not addressed by adding innovative treatments. Consider, for example, climate change and its many consequences. Among the consequences are an increase in natural disasters (e.g., floods, hurricanes, and fires); migration and immigration, as people are forced to move; extremes of temperature and weather; food and water insecurity; and air and water pollution. We know that these can increase the rates of psychiatric disorders and other mental health problems [126,127].

As a concrete example, air pollution greatly affects mental health problems [127,128,129]. Higher levels of air pollution increase the rates of depression, anxiety, autistic spectrum disorder, and suicidality, among other domains. The mechanisms through which the increase in mental health problems occurs are not known, although several have been posed (e.g., reduced exercise, greater physical health problems, direct effects of pollution on the central nervous system, inflammatory, and hormonal factors). In any case, we know that air pollutants increase the rates of mental health problems. A significant source of air pollution stems from burning fossil fuels. Worldwide use of fossil fuels continues to rise annually [130]. Thus, one can expect continued challenges resulting from air pollution on mental (and physical) health.

Environmental factors are also relevant to service delivery [131,132]. Climate change, with its many consequences, affects services and their reach. For example, increased immigration means many people are on the move to new places where they do not have basic services and access to adequate food and housing. Both physical and mental health problems are less likely to be treated among those who migrate to a new locale.

Any mental health service needs to be part of broader care that might include disaster relief, physical health care, basic amenities such as housing and food, and community support. Mental health professionals cannot provide the needed services because of their limited number (and training), and inability to control the relevant range of services that need to be provided. More displaced individuals and immigrants in a given society are not just other neglected groups but people with multiple needs and services, one of which is mental health care. The nature of that care may be different in the sense of underscoring social support at the group level (community, neighborhood) in addition to the needs of individuals for interventions directed toward a specific mental health problem.

Overall, it would be simplistic to imply that extending the list of interventions will automatically increase the scale of treatment. To be sure, many of the interventions I have noted are available and attractive (e.g., serious games, socially assistive robots) and are part of everyday life (e.g., physical activities, hobbies). This means they can be promoted for overall well-being and health rather than “mental illness” and may well be able to reach more people in need. That said, one must recognize that the challenges in treating mental disorders are intertwined with other problems (e.g., wars, natural disasters) and these influence and limit the impact that any set of techniques may have.

12. Conclusions

The article provides a perspective and viewpoint statement on mental health problems and their treatment. No effort was made to exhaust the literature on the key points. Even so, the key points were illustrated with contemporary findings and international studies on the scope of the problem and limits of current solutions. Among the key points, most individuals in need of mental health services receive none, not even one session of some intervention designed to treat their condition. The many obstacles or barriers to traditional mental health services are well studied. Some of these relate to the system of delivery (e.g., access to facilities, insurance, and too few professionals), but another set of these barriers reflects reticence on the part of the individuals in need. Most people with mental health problems do not perceive a need for treatment, and among those who do, approximately half do not see mental health treatments as a viable option.

Interventions with evidence were highlighted that can address significant mental health problems (e.g., depression, anxiety, and loneliness). These were not proposed to be used instead of traditional mental health interventions. The goal is to elaborate on the many ways in which individuals can be helped, with attention to options that have a basis in evidence. There are endless testimonials and ads (e.g., television, social media) of what can improve one’s life. The focus was on interventions that have a basis in evidence, can be scaled, and provide a set of options with the goal of reaching more of the many people in need.

Merely identifying more and more available interventions by itself will not solve the problem. More of the everyday activities need to be promoted or facilitated (e.g., at school, at work, in communities). There are already programs for walking groups, volunteer groups, and others. The next steps are to identify ways to facilitate them to reach more people and also to reach people who are often marginalized or especially underserved in a given culture. On the one hand, we are in a fortunate position. We have many intervention options that can actually help people, including, but well beyond, evidence-based psychotherapies and medications. On the other hand, next steps are needed at the level of institutional practices and policy that facilitate or even incentivize engaging in many of the practices described here.